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When Good Doctors Go Bad Lucian L. Leape, MD American Surgical Association Boston August 21, 2006 Failure to ensure that all of our colleagues are competent and safe is ethically indefensible. ACS Code of Professional Conduct Maintain competence throughout our surgical careers

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When good doctors go bad l.jpg

When Good Doctors Go Bad

Lucian L. Leape, MD

American Surgical Association

Boston

August 21, 2006



Acs code of professional conduct l.jpg
ACS Code of Professional Conduct and safe is ethically indefensible.

  • Maintain competence throughout our surgical careers

  • Respect the knowledge, dignity, and perspective of other healthcare professionals

  • Participate in self regulation by setting, maintaining, and enforcing practice standards


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Types of Performance Problems and safe is ethically indefensible.

1. The Psychopathic physician

2. The impaired physician

Substance abuse - alcohol / drugs

Mental illness

Physical illness

3. Declining Competency

4. Behavioral Problems

Disruptive physician

- Refuses to follow rules

- Abusive behavior

Abusive with patients


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Types of Performance Problems and safe is ethically indefensible.

1. The Psychopathic Physician ? 0.1%

2. The impaired physician

Substance abuse - alcohol / drugs 15%

Mental illness 15%

Physical illness 10%

3. Declining Competency


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Recertification Exam Failure Rates and safe is ethically indefensible.(2004)

Board No. % Failed

Am. Bd. Surgery

General surgery 800 4%

Subspecialties 233 9%

Am. Bd. Pediatrics

General pediatrics 3400 1%

Subspecialties 2200 4%

Am. Bd. Internal Med

Internal Medicine 3042 14%

Specialties 3054 10%

Am. Bd. Family Med 6606 11%


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Types of Performance Problems and safe is ethically indefensible.1. The Psychopathic Physician ? 0.1%2. The impaired physicianSubstance abuse - alcohol / drugs 15% Mental illness 15% Physical illness 10%3. Declining Competency 5-10%

4. Behavioral Problems

Disruptive physician


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What do surveys reveal about disruptive behavior? and safe is ethically indefensible.

NURSES:

  • Nurses witnessing or receiving it 95%

  • Verbal abuse every 2-3 months 64%

  • Believe it is a cause of nurses leaving 37%

  • Percent of doctors exhibiting it 5.7%

    HOSP EXECS: 1-5%


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Types of Performance Problems and safe is ethically indefensible.1. The Psychopathic Physician ? 0.1%2. The impaired physicianSubstance abuse - alcohol / drugs 15% Mental illness 15% Physical illness 10%3. Declining Competency 5-10%

4. Behavioral Problems

Disruptive physician ? 5%

Refuses to follow rules

Abusive behavior

Abusive with patients ? 5%


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All causes considered, 30-40% of all physicians will have a problem at some time in their career that will impair their ability to practice medicine safely.

For a hospital staff of 100, this means that at any one time 1 or 2 physicians need help.


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Why are doctors reluctant to act? problem at some time in their career that will impair their ability to practice medicine safely.

  • Distasteful to judge peers

  • Emotionally difficult – “family”

  • “Glass house” syndrome

  • Fear of retribution

  • No good mechanism


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We have a “Non-System” problem at some time in their career that will impair their ability to practice medicine safely.

  • Implicit

  • Personal

  • Punitive

    It’s “all or nothing”


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We define performance problems as disciplinary problems problem at some time in their career that will impair their ability to practice medicine safely.

  • “Hung up” on punishing

    - Want to “weed them out”

  • Safety objective: prevention


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What would we like to do? problem at some time in their career that will impair their ability to practice medicine safely.

1. Identify doctors with problems early

2. Do something about it

3. Do it in a timely fashion

We need a system


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What are the essential characteristics of an effective professional accountability system?

  • Objective - based on data, not opinion

  • Fair - applies to everyone

  • Responsive – prompt and effective treatment

    GOAL: to enable the physician to continue to practice medicine


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What would an effective professional accountability system look like?

  • Adopt performance standards

  • Adherence is a condition of appointment to staff

  • Adherence is monitored (everyone)

  • Feedback of results and action as needed

  • Broad repertoire of methods for remediation


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  • Sub par performance can be objectively defined look like?

  • Routine monitoring of all members of the medical staff is necessary to detect problems fairly and early

  • The response to deficiencies should be prompt, constructive, and sustained


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What is needed? look like?

  • Standards

  • Measures

  • Assessment and remediation programs


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ACGME / ABMS Competency Standards look like?

  • Compassionate, appropriate, and effective patient care

  • Medical knowledge and its application to patient care

  • Practice-based learning and improvement

  • Interpersonal and communication skills

  • Professionalism and ethical behavior

  • Systems-based practice


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Example of a Behavioral Standard look like?

“Treat Co-workers with Respect”

  • Hostile behavior is forbidden (raised voice, insults, public reprimands)

  • No demeaning behavior or humiliation of residents and nurses

  • No derogatory comments about colleagues – oral or written

  • Work in meaningful teams

  • Accept challenges to authority


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What measures are available? look like?

  • ABMS competency measures are being developed

    • ABIM competency testing now

  • Gerald Hickson’s analysis of patient complaints

  • PAR “360” multitrait evaluations


  • What about l.jpg
    What about: look like?

    • Annual physical exams

    • Drug testing

    • Cognitive testing


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    What is needed? look like?

    • Standards

    • Measures

    • Assessment and remediation programs


    How will we develop programs for assessment and remediation l.jpg
    How will we develop programs for assessment and remediation? look like?

    Need a collaborative effort

    ABMS

    FSMB

    JCAHO


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    Are we willing to support recovering doctors? look like?

    • Who pays for assessment and remediation?

    • How is his/her income maintained?

    • Are we willing to make refresher positions available in all of our residency programs?

    • Are we willing to mentor and supervise retrained doctors?

    • Will we let them care for our patients?


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